Product Request

Tell Us What You Need

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Computers

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Electronics

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Parts

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Sample Check

Online Check Instructions

Please enter your bank name and address

Enter your bank routing number, this number is 9 characters long and appears between the :| symbols usually at the bottom left corner of your check

Enter your checking account number, this number is 5-17 characters long and appears next to the ___ symbol at the bottom of your check and usually to the right of your routing number

Enter the Check Number that will be used for payment

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Product Request Information

For the best possible service please fill this form out completely

Today's Date: *
First Name: *
Last Name: *
Company Name:
Address Street 1: *
Address Street 2:
City: *
State: *
Zip Code: *	(5 digits)
Primary Phone: *
Alternate Phone:
Email:

	Product Information
Equipment Type:
Condition
Name Brand
Model
Product Details:

	Part(s) Search Information
Manufacturer:
Manufacture Date:
Model Number:
Product ID(LG Only):
Serial or Service Tag Number:
Operating System (Computers and PDA's Only):
Part Details

	Payment Options (If Applicable)

Payment Option 1	Online Check
Name as it Appears on the Check:
Address as it Appears on the Check:
Bank Name:
Bank Address:
Bank Routing Number:
Checking Account Number:
Check Number:
Payment Option 2:
Credit or Debit Card Number:
Expiration Date:
CSV Number: